University of South Carolina Scholar Commons Theses and Dissertations Fall 2019 An Evidence Based Rationale for Making Tick - borne Relapsing Fever a Nationally Notifiable Disease Kyle M. Hatcher Follow this and additional works at: https://scholarcommons.sc.edu/etd Part of the Epidemiology Commons Recommended Citation Hatcher, K. M.(2019). An Evidence Based Rationale for Making Tick - borne Relapsing Fever a Nationally Notifiable Disease. (Master's thesis). Retrieved from https://scholarcommons.sc.edu/etd/5603 This Open Access Thesis is brought to you by Scholar Commons. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of Scholar Commons. For more information, please contact [email protected]. An Evidence Based Rationale for Making Tick - borne Relapsing Fever a Nationally Notifiable Disease by Kyle M. Hatcher Bachelor of Arts West Virginia University, 2010 Bachelor of Arts West Virginia University, 2010 Submitted in Partial Fulfillment of the Requirements For the Degree of Master of Science in Public Health in Epidemiology The Norman J. Arnold School of Public Health University of South Carolina 2019 Accepted by: Melissa Nolan, Director of Thesis Andrew Ortaglia, Reader Eric Brenner, Reader Cheryl L. Addy, Vice Provost and Dean of the Graduate School © Copyright by Kyle M. Hatcher, 2019 All Rights Reserved. ii DEDICATION To those in the pursuit, understanding, and advancement of scientific knowledge, and to those who might benefit from its exploration. iii ACKNOWLEDGEMENTS Foremost I would like to thank my thesis chair, Dr. Melissa Nolan for approaching me with this project and helping guide me through the writing process and data summaries as well as my other committee members, Dr. Andrew Ortaglia, and Dr. Eric Brenner. Secondly, I would like to include a special thank you to Bryn Davis, M.S.P.H for her help on the regression analysis and interpretations. And lastly, I want to express my gratitude and appreciation for the wonderful cohort I was a part of during my program here. Carlos Avalos, M.S.P.H, Diana Diaz, M.S.P.H, Joshua Mercadel M.S.P.H, and Ly Tran, M.P.H, thank you for your help, friendship, and support, I would not have completed this program without you. iv ABSTRACT Tick – borne relapsing fever (TBRF) is globally dispersed, and within the United States is found primarily in the mid – west, south - west, and north – west portions of the country. TBRF is a disease which causes patients to experience flu – like symptoms and is distinguished by multiple relapses of high fever which can cause individuals to be hospitalized multiple times over months. TBRF is caused by Borrelia spp. spirochetes and spread by Onthidoros spp. soft – shelled ticks. First diagnosed in the early 20th century, the disease has gone underdiagnosed and has attracted little attention for over a century despite being the cause of illness in multiple outbreaks. Previous reviews on the subject have been limited in scope and focused on state – specific reports in localized regions of the country. The primary and secondary objectives of our review were to describe the epidemiology, scope, and clinical outcomes of TBRF to update the medical community on its impact and also to establish an evidence - based reasoning for inclusion of TBRF in the NNDSS. We present our review of TBRF as the most expansive in regard to years covered and sample size. As well, this is the only review, to our knowledge, which has collected and analyzed data by infection type. Papers selected for review had to be original case reports of TBRF infections, published in English, and have occurred in the United States. Data from similar reviews were not included nor were those papers used for analysis. Added criteria were used to collect data on cases which could be used for logistic and Poisson regressions analyzing the likelihood of clinical outcomes. After v the review process was complete, 80 papers were used for the primary analysis and 40 papers used to collect data for regression analyses. Results showed that most of TBRF infections took place in adults and children. Men were statistically more likely to be infected than women (p= <0.0001). Symptom profiles for causative agents confirmed flu- like symptoms as the most reported (headaches, vomiting, chills/sweats) but revealed that many symptoms were statistically more likely to be found in B. turicatae infections compared to B. hermsii infections, indicating that infection type influences clinical presentation of the disease. Modeling febrile episodes and Jarisch – Herxheimer reactions on treatment type hinted that some treatments are better than others but no statistically significant claims can be drawn from this analysis. In conclusion, this review highlights important differences between our results and prior published literature reviews, as well as provides recommendations on reporting practices, treatment protocols, and future work while arguing that TBRF should be a nationally notifiable disease and reported to the NNDSS. vi TABLE OF CONTENTS Dedication .......................................................................................................................... iii Acknowledgements ............................................................................................................ iv Abstract ................................................................................................................................v List of Tables……………………………………………………………………………viii List of Figures………………………………………………………………………….....ix List of Abbreviations ...........................................................................................................x Chapter 1: Introduction……………………………………………………………………1 Chapter 2 Methods ...............................................................................................................8 Chapter 3 Results ...............................................................................................................11 Chapter 4 Discussion .........................................................................................................23 References ..........................................................................................................................37 Appendix A: List of papers used in final analysis in alphabetical order by author ...........41 vii LIST OF TABLES Table 3.1 Primary demographic characteristics of TBRF cases ........................................17 Table 3.2 Symptom profile of TBRF cases .......................................................................18 Table 3.3 Prognostic indicators of TBRF by causative agent ............................................19 Table 3.4 Characteristics of infection ................................................................................21 Table 3.5 Results of logistic regression modeling JH reaction and treatment comparison.……………………………………………………………………22 Table 3.6 Results of Poisson logistic regression modeling number of febrile episodes and treatment type. ...................................................................................22 viii LIST OF FIGURES Figure 3.1 Flowchart displaying search process and record selection for analysis ...........16 Figure 3.2 Incidence of infections described over the decades .........................................19 Figure 3.3 Incidence of infections by month .....................................................................20 Figure 3.4 Shaded map of confirmed or suspected TBRF cases identified in final analysis. .....................................................................................................................20 ix LIST OF ABBREVIATIONS BH………………………………………………………………………...Borrelia hermsii BT………………………………………………………………….…....Borrelia turicatae CDC………………………...…United States Centers for Disease Control and Prevention CSTE…………………………………….Council of State and Territorial Epidemiologists IRR…………………………………………………………………. ....Incidence rate ratio NNDSS………………………………....National Notifiable Disease Surveillance System OH……………………………………………………………………..Ornthidoros hermsi OT…………………………………………………………………….Ornthidoros turicata TBRF………………………………………………………...Tick - borne Relapsing Fever x CHAPTER 1 INTRODUCTION The National Notifiable Diseases Surveillance System (NNDSS) is a network of systems run by the United States Centers for Disease Control (CDC) and Prevention which works on a national level to compile data on disease incidence, distribution, disease agents, and host factors. The NNDSS works in conjunction with the Council of State and Territorial Epidemiologists (CSTE), whose job it is to provide a recommended list of nationally notifiable diseases and coordinate with state and local health departments and health agencies, which provide case data for informing periodical updates to the list of nationally notifiable diseases.1 Disease reporting begins on the state and local level with cases identified by health providers, hospitals, and laboratories. State legislatures, on recommendation from health agencies and health professionals, dictate which diseases are mandatorily reported allowing for state funds to be utilized accordingly.2 There are many diseases which are universally reported, such as salmonella outbreaks and highly contagious vaccine- preventable infectious diseases. Other diseases, which are found regionally, are sporadically reported depending on the incidence of disease. Because there are no federal laws which dictate disease reporting, conveying information to the